Laserfiche WebLink
SAN JOAQU --OUNTY ENVIRONMENTAL HEALTH ,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Q 45 ST'AT(bt4 <br /> OWNER/OPERATOR <br /> S Z t1 / c✓o CHECK If BILLING ADDRESS E] <br /> FACILITY NAME V c�f� L `Q <br /> SITE ADDRESS pS <br /> Street Number Direc ion l Street Name w, Cit /ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) •� �Y© S -3 r I Tr i`t t(4v <br /> ( {)r , n <br /> v treat Number Street NNaml q /� <br /> CITY AO b U iN STATE 1 ZIP 1 W <br /> PHONE#f EXT APN# LAND USE APPLICATION# <br /> (�S3► �R b - �'�oa <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS"!"` <br /> BUSINESS NAME PHONE EXT. <br /> HOME Or MAILING ADDRESS (CS 0 L A , (q&) r 4�n <br /> `V v �J .1.11 k. /ZL� l73 �i V <br /> CITY 40" <br /> STATE e4 ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> DATE: S(I�� lll+V,e�d <br /> APPLICANT'S SIGNATURE: �,P=c2 �'�. V, ` <br /> PROPERTY/BUSINESS OWNER[I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT't 0W-'MLM Liy <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: u S1 <br /> ( <br /> COMMENTS: k-o- CL -(—, (+ f tt, <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />